Ruminations by a non-academic general surgeon from the heart of the rust belt.

Tuesday, August 18, 2009

Fixing Primary Care

From KevinMD, Dr. John Horstkamp has a piece detailing his ideas for fixing the primary care shortage in America. With universal coverage of all Americans seemingly on the horizon in some form or other, now would be a prudent time to address a very disturbing question: will we have enough doctors to take care of the influx of new patients?

Less than 5% of graduating medical students are entering primary care fields. The reason most cited for this phenomenon is the relatively low remuneration for primary care compared to subspecialist physicians. Dr. Horstkamp feels that substantially raising the reimbursement rates for cognitive medicine is the only viable solution. And by substantial, he isn't kidding. In the reform bill floating around DC now, there is a proposal to raise Medicare reimbursement rates by 8-10% for primary care docs. This isn't going to cut it, according to Dr Horstkamp. He wants fees raised by 30-70%. If you're thinking to yourself--- "wow that sounds really.....ridiculously, absurdly high"--- well, you're right. It is absurd. It's a juvenile, disingenuous entreaty for "equality". Let's delve into it.

His first error is the premise that all doctors are alike. Specialists can generally earn $100,000 more per year than most primary care providers. They also train longer, face higher malpractice premiums, and often endure higher levels of stress and personal strife. Over the course of a career, that difference can mean an additional $3 million dollars in earnings. One response to this actuality is to be morally appalled (the horror, the horror! The GI doc just made 400 bucks for a fifteen minute EGD!). Another is to say, so what? So there are discrepancies in how the market decides to remunerate certain kinds of doctors. Big deal. I just don't think you make any meaningful reform-minded progress going down this pathway. There will always be unfair differences in the way people are paid in a free and open market. Maybe our inner city schools wouldn't be such a collective cesspool if teachers made six figures. Or maybe indigents standing trial would get a better defense if their court appointed attorneys were paid the same as the Wall Street corporate lawyers (i.e. sharks). But you don't know for sure. And simply equalizing all salaries across the board is an overly simplistic solution to an incredibly complex reality. Demanding a 70% increase in pay just comes across as an unserious plea for fairness. It's like the fireman complaining to his boss about how Michael Vick just signed a million dollar contract. Yeah, it probably isn't right that a convicted felon/dog torturer makes ten times as much as the guy who pulls innocent grannies out of burning apartment buildings, but hey, that's the way it is. It's the dark side to free market capitalism.

No doubt, we can remunerate cognitive medicine far better than how it is now. And I think the 8-10% increases articulated by the bill are a great start. And student loans ought to be forgiven for ANYONE who goes into primary care, not just those who agree to take jobs in Cody, Wyoming. So now you're changing the terms of the argument. All of a sudden, primary care rebrands itself as a well-respected profession with earnings $150,000-250,000 and no student loan debt to worry about. You get to be a family doc. You work hard. You don't owe any money. You're going to be able to live the upper middle class suburban life. What's not to like?

But here's the thing with increasing pay for primary care docs. The practice of medicine must concommitantly change. I've written about this before. It can't be business as usual. No more shotgun consults. No more rushing through 45 patients during office hours and shunting off any complicated patients on subspecialists. No more referring all your asthmatics to pulmonologists. No more pawning off your stable type II diabetics on endocrinologists. No more dermatology referrals for obvious benign moles. There has to be a change in the practice of primary care medicine. So if we increase remuneration for cognitive medicine, it ought to allow docs to spend more time with their patients. And this may mean that average income won't change at all because they're seeing fewer patients.

It isn't about money. (Or at least it's not supposed to be). It's about job satisfaction and being able to do something noble and meaningful for a fair compensation. Worrying about what other professions are making is a fruitless, endless exercise in self abnegation....

12 comments:

Anonymous
said...

Lately I have given thought to the idea that newer internists have been molded by all of these forces, in a more damaging way than any other specialty. I feel for those who have come out of school only to practice in an environment where putting your brain through it's paces is living dangerously. You don't just get that edge back easily, when you've lost momentum. This is bad in more ways than the obvious.

I have an image of a good Internist friend of mine. I watch him on the floor muttering to himself, crabby. This sadly, for some reason cracks me up. He has started to remind me of my 82 year old father. Poor guy, he's only 40. It's like somebody tripped a racehorse.

I always find it interesting how incredibly different things work in different parts of the country; sometimes even in different areas of the same city.

I have no doubt that your version of primary care "business as usual" is what you've seen, but it's a far cry from the way I and many other FPs practice. Stable, controlled type II diabetics? I see them regularly, until the surgeon who takes out their appendix emergently tells them they should be seeing an endocrinologist. Same thing for asthma, migraines, IBS, and complex patients with multiple chronic diseases.

The issue isn't about what other specialties make per se, but that the reward for their extra training up front is disproportionate to the time they put in. Each extra year of training (with its concomitant responsibility, including malpractice risk) should lead to extra compensation, but it ought to be additive and not multiplicative. I have no problem with you making twice as much as me if you trained twice as long, but why six to eight times as much? Each extra year seems to multiply the final salary instead of just adding to it.

The real advantage of increasing payment for cognitive medicine is not just to increase pay for primary care, but to create rational incentives for all specialties. If a GI gets paid about the same to explain why an IBS patient doesn't need another colonoscopy as he does for just doing it, patient care (and satisfaction with that care) will improve, and only people who really need procedures (and therefore exposed to the risks of those procedures) will get them. It's a win-win for everyone.

Good primary care depends on the pcp - my own experience was that I suffered for 5 years with all the symptoms of hypothyroidism (extreme fatigue, thinning hair, unexplained weight gain, downward spiraling depression) - but a TSH within normal range. The pcp checked TSH (and only TSH) - ignoring my symptoms and my previous medical history always telling me nothing was wrong with my thyroid.

No great cognitionist, apparently. (actually 3 in the same practice gave me the same answer over those 5 years). Not one of them thought to dig deeper for an explanation (I assume they forgot all they ever learned about the endocrine system) or refer me to an endocrinologist.

I had to get Ovarian Cancer (freak diagnosis - made because the gyn had a new sono machine and referred all her new patients for transvaginal sonos - not the standard of care for young women - I assume to up her income - worked in my favor, I'd say) to be properly diagnosed. How? The PET scan at conclusion of treatment revealed a thyroid lit up like a Christmas Tree.

I was referred back to my PCP. Again the TSH came back as normal - Again - I was dismissed (by this time the practice had its nurse call with test results). The nurse was on the verge of hanging up when I asked how we reconcile two different test results - a PET scan that unequivocally noted an abnormality and a TSH that did not. Why did I have to ask that question? Why didn't the doctor review the test and ask that question?

The nurse asked "Well, would you like to see an endocrinologist?" Didn't know there was a specialist for thyroids. Hell, yes, I said.

After waiting two months for an appointment, a full thyroid panel and clinical exam (palpable nodulous thyroid) revealed all that needed to be known to properly diagnose my hypothyroid disease. 5 years of suffering needlessly. (It was clear from the PET scan that this had been going on for quite some time).

These internists must pay attention to more than numbers on a lab sheet. There are subtleties to many diseases that require thoughtful review - repeatedly ignoring symptoms in favor of lab tests is inexcusable. Not all your patients are obese, whining, attention-seeking idiots.

Back in the day my family doc (different doc, different city) was the one who kept up with my symptoms over the course of several weeks eventually referring me for a biopsy diagnosing lymphoma.

Notably, the blood tests were within normal ranges then, also - highly unusual - but it does happen. I shudder to think of the outcome had the pcp's I was seeing during the thyroiditis symptoms been in charge of my care. I guess I wouldn't be here - and there never would have been thyroid disease to diagnose.

There you have it - two extremes - sub-optimal primary care - and good, thorough, thoughtful primary care. Now, how do we patients tell the difference?

Buckeye, Good thing you're a surgeon. You'd never make it as an economist. This guy was making a supply/demand statement. If the country wants more family docs, then the pay must go up. Then you get all hung up on what slackers the primary care docs are--that's called "Just Price Theory" and it went out a couple hundred years ago. We got an new gig called "the market economy."

I think this is quite critical to the current health care debate. I am appalled at the number of PCPs who are proponents of the bill, simply because they believe their pay will increase. In all likelihood, ten years from now; their pay will be relatively unchanged.The key here, however, is the difference in primary care practices. Having grown up in the Baltimore-DC metro area, I am quite accustomed to shadowing physicians who do the 5-min oil change and charge a fortune. On the flip side, I have shadowed physicians in rural West Virginia who spend at least 30min per patient.

How can we determine the quality of care? And how to fairly reimburse the physician?The rural physician cannot simply shunt off his pts to a specialist. He performs minor procedures in house and spends quality time with the patient to ensure their needs are met. He knows his patients needs and whether or not he can help them financially. However, his patient population is one of the worst in America. Everyone is obese, diabetic, hypertensive, etc... Unlike the metro area physician, his patients do not eat organic foods and run two marathons on the weekend.

The rural physician is remunerated at a significantly lower rate (mostly Medicare/aid patients), while the DC metro area is rapidly switching to over to high-fee concierge practices (not taking any form of insurance at all).

Therefore, how can we accurately reimburse a physician for the job he is doing. Even though the rural physician practices "cognitive" medicine, he may be penalized with poor patient outcomes.

Show me a market-driven American conglomerate that's not marred by mounting debt, poor management +/- excessive risk-taking market behaviors. I will give you 3 behemoths that are: BAC, BA & GM. Health care in US is following the dangerous trend.

Glad that you are not a health profession or behavioral analyst. Screw your gig: current crisis highly suggests that it is not sustainable. Health care is not some market place where you can close your shop after 2-3 decades of short-term profit.

Buckeye, you're painting all primary care docs with a broad brush. I can point to numerous specialists/ surgeons that seem to be quick on the trigger for a procedure. That does not mean that all or most are money-grubbing docs. If reimbursement to primary docs is increased, more med students will go into primary care, and I bet it will be proportional to the amount of increase in pay. However, you still will be left with some primary docs that are quick to consult and order tests for the same reasons they are now. You can make more money by seeing more patients. It depends on the moral compass and makeup of the individual. The only way to make a large dent in this is to reward docs that practice efficient, appropriate care. Unfortunately, this can only be done by insurance companies or the government, both of which have their shortcomings.

I have usually agreed with you in the past but you WAY missed the mark with this post. It's easy to take cheap shots and say primary care docs refer anything that's the least bit difficult and run 40 patients a day through their office. The problem is, you're wrong. I don't know ANYBODY who sees 40 patients a day, and most of the primary care docs I know do the best they can with the time they have. In my Texas town NOBODY gets referred to an endocrinologist for Type 2 diabetes, and even the ones that self refer usually stop going since they get tired of seeing the NP.

I would love to hear your thoughts on stimulating third and fourth year medical students to choose primary care careers. They don't want to do it now, since they will earn 1/3 the salary for a whole lot of work. What makes you think a 5% or 10% salary boost is going to make any difference? Will a pay increase from $150k to $165k really yank a medical student away from that $500k radiology job? (Actually, the established radiologists here, once full partner in the group, make over $1 million.)

And for what it's worth, no market determines primary care salaries. The payments are arbitrarily fixed by a specialty-dominated cabal called the RUC. Primary care docs don't make 1/4 the salary of specialists because that's all they deserve or are worth. They earn so little because a group of specialists decided they should be paid less so the specialists can be paid more.

You mention what a GI gets for performing an endoscopy. Why should he be paid triple the money for 30 minutes of his time compared to his residency colleagues who chose general medicine? If you believe doing a colonoscopy is more difficult than juggling a sick 80 year old diabetic with ESRD, CAD, temporal arteritis, a fib and leg cellulitis all in 20 minutes, then I have to wonder about your judgment. If the colonoscopy isn't harder, why should it pay triple?

It's quite clear in your post that you feel you as a surgeon do more valuable things and are simply more valuable altogether than mere primary care docs, and thus there's no way they should be paid anything more than a fraction of your pay. Well, who said you're more important? Or smarter? Or more dedicated?

You ought to read this post.http://www.thehealthcareblog.com/the_health_care_blog/2009/08/-commentology-thoughts-on-the-death-of-primary-care-.html This describes what primary care is really like, and also illustrates why it must be saved.

Hey guys, I'm not trying to take "cheap shots" at primary care. My point is simple. If we can remunerate pcp's such that they can make a a good living without being forced to rush through a billion patients a day, and rely on specialists for more detailed care, then Im all for it. As a general surgeon, I don't see what a pcp does on a regular basis; so you're right, I could be way off the mark. But I do see hospital-based medicine. And rarely do I see an internist manage fever, CHF, etc on their own. The main reason is because they're too busy. They have to see 15 patients in the hospital and then show up for a full office schedule. It's an impossible demand. My point is this--- once we make it financially feasible to spend more time on individual patients, see fewer patients, then we ought to hold those pcp's accountable to such a practice. It shouldn't be just an opportunity to "make more money" by practicing medicine the same way, i.e. seeing 40 patients a day.

Listen, as the country surgeon above states, I'm right there with primary care docs. General surgeons have been getting screwed for the past 15 years in terms of decreasing reimbursements and the 90 day global period. And that's why we're anticipating a gen surgeon shortage that may be worse than what is expected for primary care. I would love to cover one hospital, round on my post ops 4 or 5 times a day and spend 45 minutes with all my office patients. But I cant afford to.

And if you get the impression from my post (I'm still searching for the wording that gives you that idea) that I feel I am "more valuable" because I am a surgeon, well, I'm sorry you feel that way because it's certainly not the stance I hold.

If the only way to get younger med students to go into primary care is to pay them commensurate to what radiologists make....well, good luck with that. Radiologists make too much. So do dermatologists. So do some orthopedic specialists. But that can't be our goal. It's just not economically realistic.

Buckeye- I wonder if you've seen an article in the Atlantic Monthly about paying and restructing health care? Don't let the title fool you: "How American Health Care Killed My Father" by David Goldhill http://www.theatlantic.com/doc/200909/health-care

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